Skip to main content

Intake and Referral Information Checklist

The following information is needed to complete the phone interview for the ADvantage Program.

Personal Information:

  • Legal name
  • Date of birth
  • Social security number
  • DHS case number (if applicable)
  • Medicare and Medicaid numbers (if applicable)
  • Mailing and/or physical address with driving directions
  • County
  • Telephone number
  • Marital status
  • Veteran status
  • Gender
  • Race and ethnic background
  • Citizenship, legal residency, and/or country of origin
  • Primary language
  • Number of people living in the home and relationship to the applicant
  • Type of employment the applicant did when he/she worked
  • Highest grade completed in school (trade school, some college or college degree, etc.)

Medical Information:

  • Primary care physician's name, address and phone number
  • List of difficulties and/or medical diagnosis from doctor
  • Is the member homebound? Can the applicant walk out of the home independently?

Financial Information:

  • Monthly income sources (include amount of welfare and food stamps, if applicable)
  • Assets: amount and source of any investments, burial policies or life insurance policies. If land or home is owned other than where the member resides, you will also need a description, location and any other details that can be provided if possible. Also need any property transactions completed within the last five years (transferred, given, or deeded to another party)
  • Source of any other insurance, such as secondary, HMO, Veterans, or Indian CDIB.

Other Contacts (Include all telephone numbers, addresses, and relationship to member, if applicable):

  • Name of person calling to complete the application
  • Emergency contact (not living in the home with the applicant)
  • Next of kin (living in the area if applicable)
  • Power of attorney
  • Legal guardian

When you have gathered all information needed to complete a 10-15 minute phone interview, please call the AAU at 800-435-4711.

Back to Top